Epidemiology and Treatment Outcome of Blast Injuries to the Hand at a Tertiary Hospital of Kashmir Valley, India

Introduction

Hand injuries are the one of the most common musculoskeletal injuries encountered in emergency wards.^[1,2] An increased surge has been seen secondary to the use of machines, fireworks, and violence-related cases.^[3,4] Injuries are varied and can be combined with injuries to other areas of the body.^[5] In addition, the severity is varied so is the intervention ranging from conservative management to amputation.^[6,7] Patients with acute hand injury experience a temporary or permanent loss of hand functions and keeping in view the specific functions of hands, loss of these functions can have a varied impact in the quality of life both in short and long term.^[8,9] Isolated blast injuries to the hands are usually seen in the civilian population as a result of accidental explosions of firecrackers or fireworks, gunshot injuries, and handling of a low-grade explosive like tear gas shells.^[7,8] The extent of injury depends on the closeness or the proximity of the hand and also on the size of the explosive. Blast injuries present with a wide range of wounds, that is, laceration, avulsion, amputation, burn, vascular, compartment syndrome, crush injury, and degloving injury. Blast injuries can have disastrous consequences.^[7] The pattern of isolated hand injuries is quite different from those of large scale blast injuries as these usually happen on account of low-grade explosives or firecrackers.^[10] The predominance of hand involvement in such injuries is due to accidental blast during hurling a bomb as well as the injury sustained when a person tries to shield himself from a bomb being hurled at him with his hands.^[11] To date, there are few studies that have investigated the epidemiology and outcome of blast injuries to hand in Kashmir Valley.

To address these research gaps, we investigated the pattern, etiology, and outcome of blast hand injuries reporting to the plastic surgery department of the sole specialized plastic surgery department in Kashmir Valley.

Materials and Methods

Results

We included a total of 26 cases of isolated blast injuries to hand in our study. Two subjects were excluded as they were lost to follow-up. The participants had a mean age of 23.12 ± 9.1, with age ranging from 10 to 54 years. Only one subject was a female with the rest 25 being males. The most common source of injury was tear gas shells 16 (61.5%), followed by stun shells 5 (19.2%) and firecrackers 3 (11.5%). Dominant hand was affected in 22 (84.62%) of cases. Fracture of any hand or wrist bone was present in 19 (73.08%) cases with 8 (30.77%) and 7 (26.92%) cases requiring any revascularization surgery and amputation respectively. Table 1 describes the sociodemographic and clinical profile of the study participants.

Functional outcome at follow-up

The mean QuickDASH score at follow-up was 37.24 ± 29.7. The QuickDASH at follow-up was significantly associated with the HISS score with higher scores seen with higher HISS score (r = 0.67, p = 0.0012). QuickDASH was not significantly associated with age and cause of injury. Figure 1 depicts the correlation between HISS and QuickDASH scores.

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Figure 1

Scatter plot depicting correlation between hand injury severity score (HISS) and quick disabilities of the arm, shoulder and hand (QuickDASH) scores.

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Discussion

Our study describes the pattern of blast injuries to hand and their treatment outcome from a single tertiary care hospitals of Kashmir Valley, India, between 2016 and 2020. Our study includes 26 participants that met the inclusion criteria and included 25 males and a single female participant who had a firecracker-related blast injury to hand. We employed validated tools to describe the extent of injury as well as the functional outcome after the surgery. More than two-third participants had a severe or major blast injury to any hand and around three-fourth had an associated fracture of any hand or wrist bone. Revascularization/reimplantation was done in eight participants with seven subjects needing amputation of any part of the hand. The average QuickDASH score at follow-up was 37.24 ± 29.7. QuickDASH score at follow-up was positivity correlated with HISS score at the time on injury meaning higher grade injuries tend to have a long-term functional impairment.

The most common source of injury was tear gas shells (61.5%), followed by stun shells (19.2%) and firecrackers (11.5%). Mobile phone and pressure cookers were the sources of blast for one case each. The study area saw few events of political protests during these years in which tear gas and stun shells were used by administration to control protests. Low-grade explosives like tear gas stun shells are considered to be a nonlethal method of crowd control and sometimes the protestors try to handle these low-grade explosives during which the same may explode while in hand and lead to blast injuries of hand. In studies conducted in other parts of India, firecrackers are the most common source of injury.^[10,17]

The subjects who reported with any blast hand injuries were primarily young males as most subjects were males aged less than 30 years. The primary reasons for the same could be the fact that most study participants had injuries due to handling of tear gas/stun shells during political protests in the study area. Participation in these protests is primarily from males and specifically young males which puts them at risk of blast injuries. The findings are similar to other studies as other studies have also found males to be more commonly affected than females.^[1,8]

As the handling of these low-grade explosives is primarily done by the dominant hand, it tends to be the most commonly involved hand. In our study, dominant hand was involved in 84% of cases. This finding is in agreement with multiple other studies.^[17,18] Greater dependence on dominant hand for routine activities means that functional outcome after recovery is very important for ensuring no or very limited residual disability.

Hands are integral components of almost all human functions ranging from routine work to highly specialized activities as most skills are expressed by intricate use of hand movements. Any long-term disability can be devastating and severely impair one's quality of life and capacity to lead to a socially and economically productive life. The QuickDASH at follow-up was significantly associated with the HISS score with higher scores seen with higher HISS score (r = 0.67, p = 0.0012). Higher severity of injury has been shown to be associated with poor outcome in multiple other studies also.^[12,16]

Conclusion

Blast injuries to hands are primarily seen in young males with low-grade explosives being the primary source of injury. Dominant hand is most commonly involved with many cases needing revascularization procedures. It often results in long-term functional disability. The QuickDASH at follow-up was significantly associated with the HISS score with higher scores seen with higher HISS score.